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Chance Favors the Prepared Community:
Preparing for a Flu Pandemic
February 14, 2007Mark J. Levine, MD MPH
BIRD FLU PANDEMIC?
Influenza Virus
Single-stranded RNA virus
Surface membrane spiked with 2 types of protein– Hemagglutinin
(H)– Neuraminidase
(N)
Influenza Virus Composition
Type of nuclear material
Virus type
Geographic origin
Strain number
Year of Isolation
Virus subtype
A/Beijing/32/92 (H3N2)
Hemagglutinin
Neuraminidase
“The pandemic clock is ticking, we just don’t know what
time it is”
E. Marcuse
Pandemic influenza: definition
Pandemic influenza, or flu, is a global outbreak of disease that occurs when a new influenza A virus appears in humans, causes serious illness and then spreads easily from person to person.
“A pandemic is the viral equivalent of a perfect storm. There are three essential conditions, which rarely converge, and
they are impossible to predict.”
Michael Specter, The New Yorker
The three conditions…
1. A new subtype that has not infected people in the past
2. Causes severe illness in people
3. Sustained transmission from person to person
Emergence of pandemic strain = most significant public health emergency caused by a naturally occurring pathogen
Timeline of Emergence of Timeline of Emergence of Influenza A Viruses in HumansInfluenza A Viruses in Humans
1918 1957 1968 1977 19971998/9
2003
H1
H1
H3H2
H7H5H5
H9
SpanishInfluenza
AsianInfluenza
RussianInfluenza
AvianInfluenza
Hong KongInfluenza
Effects of Typical Flu Season (U.S.)
5-20% ill
200,000 hospitalizations
36,000 deaths
Impact of Past Influenza Pandemics/Antigenic Shifts
Pandemic, or Antigenic
Shift
Excess Mortality
Populations Affected
1918-19(A/H1N1)
500,000 Persons <65 years
1957-58(A/H2N2)
70,000 Infants, elderly
1968-69(A/H3N2)
36,000 Infants, elderly
Moderate (1957-like)
Severe (1918-like)
Illness 90 million (30%) 90 million (30%)
Outpatient medical care
45 million (50%) 45 million (50%)
Hospitalization 865,000 9,900,000
ICU care 128,750 1,485,000
Mechanical ventilation
64,875 745,500
Deaths 209,000 1,903,000
Planning Assumptions:• 30% attack rate• 50% or more of those who become ill will seek medical care• Number of hospitalizations and deaths will depend on the
virulence of the pandemic virus
Pandemic Prediction: U.S.A.
Moderate (1957-like)
Severe (1918-like)
Illness 360,000 (30%) 360,000 (30%)
Outpatient medical care
180,000 (50%) 180,000 (50%)
Hospitalization 3,460 39,600
ICU care 519 5,940
Mechanical ventilation
260 2,970
Deaths 836 7,612
Planning Assumptions:• 30% attack rate• 50% or more of those who become ill will seek medical care• Number of hospitalizations and deaths will depend on the
virulence of the pandemic virus
Pandemic Prediction: Central Region
Standard operations
Expanded capacity-
Out of hospital
3200 3900
????
0 days 10 days
Sudden surge from a immediate event
Standard operations
Expanded capacity-
Out of hospital
3200 3900
????
0 days 10 days- 3 months
Biological attack or Pandemic ?
Care in the community
Slowly growing surge from a rolling event:
The Influenza Pandemic of 1918-191925-30 percent of the world’s population fell ill
500,000 deaths in the US
25-30 percent of the world’s population fell ill
500,000 deaths in the US
25-30 percent of the world’s population fell ill
500,000 deaths in the US
1918 Pandemic
Avian Influenza H5N1as of February 7, 2007
55 countries with documented H5N1 avian influenza in bird populations
11 countries with documented human cases of H5N1
Nations With Confirmed Cases
H5N1 Avian Influenza (Feb ‘07)
Cumulative Number of Confirmed Human Cases of Avian Influenza A/(H5N1) Reported to WHO as of
02/06/07
Country 2003 2004 2005 2006 2007Tota
l
cases deaths cases deaths cases deaths cases deaths cases deaths cases deaths
Azerbaijan 0 0 0 0 0 0 8 5 0 0 8 5
Cambodia 0 0 0 0 4 4 2 2 0 0 6 6
China 1 1 0 0 8 5 13 8 0 0 22 14
Djibouti 0 0 0 0 0 0 1 0 0 0 1 0
Egypt 0 0 0 0 0 0 18 10 2 2 20 12
Indonesia 0 0 0 0 19 12 56 46 6 5 81 63
Iraq 0 0 0 0 0 0 3 2 0 0 3 2
Nigeria 0 0 0 0 0 0 0 0 1 1 1 1
Thailand 0 0 17 12 5 2 3 3 0 0 25 17
Turkey 0 0 0 0 0 0 12 4 0 0 12 4
Viet Nam 3 3 29 20 61 19 0 0 0 0 93 42
Total 4 4 46 32 97 42 116 80 9 8 272 166
Integrated Planning for a
Large Scale Health Emergency
The Public Health SystemThe Public Health System
MCOs
Home Health
Parks
Economic Development
Mass Transit
Employers
Nursing Homes
Mental Health
Drug Treatment
Civic GroupsCHCs
Laboratory Facilities
Hospitals
EMS Community Centers
Doctors
Health Department
Churches
Philanthropist
Elected Officials
Tribal Health
Schools
Police
Fire
Corrections
Environmental Health
Accountants!
National Preparedness
CommunityPreparedness
Business and Organizational Preparedness
Individual and Family Preparedness
Pandemic Flu Preparedness for Individuals and
Families
http://www.pandemicflu.gov
Pandemic Flu Preparedness for
Businesses
http://www.pandemicflu.gov
In a Pandemic…
Despite all preparedness efforts, Virginia will not be spared from a flu pandemic.
AllAll businesses, hospitals and government agencies will feel the effects of a pandemic.
Ten to 25 percent of the workforce may be ill at any one time.
Unlike other disasters, a flu pandemic will touch every population in every part of the country. Moving operations to another location may not be a viable option.
A flu pandemic could cost the U. S. economy billions of dollars in lost productivity and medical expenses. During a pandemic, it will not be business as usual.
The number one thing you can do to
prepare for a pandemic is to learn as much as you can and personally plan
ahead of time
Local Emergency Planning and
Response Framework
Health Districts in Virginia
Preparing for Emergencies in the
Face of Uncertainty
Hope?
Hope is not a strategy…
Julie Gerberding, Director, Centers for Disease Control and Prevention
Chance Favors the Prepared Mind
Louis Pasteur
Chance Favors the Prepared
CommunityMark Levine
What is a
“Prepared Community?”
Incident Command Structure
Incident Commander
Planning Operations Logistics Finance/Admin
Safety Officer Public Information Officer
Liaison Officer
Division
Group
Unit
Supply Unit
Resource Unit
Food Unit
Unified Command(Representatives From Local
Jurisdictions)
Finance/ Administratio
n
LogisticsPlanningOperations
Unified Command
Components of Local Response
Communication/AwarenessSurveillance/InvestigationContainment/Control
– Distribution of antivirals/vaccineHealthcare Surge
Components of Local Response
Communication/AwarenessCommunication/AwarenessSurveillance/InvestigationContainment/Control
– Distribution of antivirals/vaccineHealthcare Surge
Communication/Awareness
Virginia Department of Health– http://www.vdh.virginia.gov/pande
micflu/
Henrico County Health
Department– http://www.co.henrico.va.us/health
/
CDC– Travel: http://www.cdc.gov/travel/– Avian flu: http://www.cdc.gov
/flu/avian/
Continued…
Education/Information Exchange– Public Health: Epi-X, CDC– Medical community: Public
Health Bytes•www.publichealthbytes.org
– General community: Promote individual/family preparedness•www.pandemicflu.gov•Media spots•Health Department Web site info
Components of Local Response
Communication/AwarenessSurveillance/InvestigationSurveillance/InvestigationContainment/Control
– Distribution of antivirals/vaccineHealthcare Surge
Surveillance and Detection
-current status-Surveillance is a routine
function of the Health Department and is always ongoing
Influenza surveillance is not something new and is already very extensive
Enhanced surveillance experience/process already in place
Additional Surveillance Efforts
Syndromic Surveillance– Surveillance for symptoms of
disease rather than actual cases– May detect a disease outbreak
sooner
Ongoing issues
Communication/AwarenessSurveillance/InvestigationContainment/ControlContainment/Control
– Infection Control measuresInfection Control measures– Distribution of antivirals/vaccineDistribution of antivirals/vaccine
Healthcare Surge
NPI
Summary of NPI
Isolation and treatment of people infected with pandemic flu strain
Voluntary home quarantine of members of households with pandemic flu strain
Social distancing – Children: school closure and out of
school social activity suspension– Adults: Cancellation of public
gatherings; alteration of workplace environments
CDC PandemicSeverity
Index
Meteorology Meteorology Geology
Saffir-Simpson
Hurricane Scale
FujitaTornado
Scale
RichterEarthquake
Scale
0 - 73 MPH 0 - 39 MPH 0
Category 1 >74 MPH F0 40 - 72 MPH 1 No damage
Category 2 >96 MPH F1 73 - 112 MPH 2 No damage
Category 3 >111 MPH F2 113 - 157 MPH 3 Little damage
Category 4 >131 MPH F3 158 - 206 MPH 4 Light damage
Category 5 >155 MPH F4 207 - 260 MPH 5 Moderate damage
F5 261 - 318 MPH 6
Mod.-Heavy damage
F6 319 - 379 MPH 7 Heavy Damage
8 Very Heavy Damage
9 Total destruction
10 Unheard - never seen
Pandemic Severity Index
Interventions by Setting 1 2 and 3 4 and 5
Home
Voluntary isolation Recommend Recommend Recommend
Voluntary quarantine Generally not recommended
Consider Recommend
School
Child Social Distancing
School closure Generally not recommended
Consider: <= 4 weeks
Recommend: <= 12 weeks
Out of school activity restrictions Generally not recommended
Consider: <= 4 weeks
Recommend: <= 12 weeks
Workplace/Community
Adult Social Distancing
Decrease number of social contacts Generally not recommended
Consider Recommend
Increase distance between people Generally not recommended
Consider Recommend
Modify/Postpone public gatherings Generally not recommended
Consider Recommend
Modify workplace schedules Generally not recommended
Consider Recommend
Ongoing issues
Communication/AwarenessSurveillance/InvestigationContainment/Control
– Distribution of antivirals/vaccineHealthcare SurgeHealthcare Surge
HENRICO MEDICAL RESERVE CORPS
http://www.vdh.virginia.gov/LHD/henrico/myweb/mrc.asp
Goal of Planning for Large Scale
Health Emergencies
Enhance our capacity and ability to better perform our day to day tasks and build
capacity to ramp up for large scale health issues
Questions to AskHow will you maintain your business
operations when 10 to 25 percent of the workforce falls ill at one time?
How can you adapt your existing continuity of operations plans to reflect this kind of human resources impact?
How will you cope when the other businesses and suppliers you rely on experience the same absentee rates?
Continued…How will you adapt to disruptions in the
supply chain for the raw materials you need and how will you get your product to the consumer if your distribution network is hit with high absentee rates?
How can existing return-to-work and travel policies be adapted to control the spread of this virus among employees?
How will you limit the economic impact of a flu pandemic on your business?
Chance Favors the Prepared Mind
Louis Pasteur
Chance Favors the Prepared
CommunityMark Levine